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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609657
Report Date: 04/06/2022
Date Signed: 04/06/2022 02:28:05 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/28/2022 and conducted by Evaluator Patrick Shanahan
COMPLAINT CONTROL NUMBER: 31-AS-20220228145842
FACILITY NAME:HORACE ASSISTED LIVINGFACILITY NUMBER:
197609657
ADMINISTRATOR:TERZYAN, SEROBFACILITY TYPE:
740
ADDRESS:17355 HORACE STTELEPHONE:
(818) 439-8482
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: 4DATE:
04/06/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Serob/ AdministratorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Resident is forced to remain in their bed while in care.

Staff unable to effectively communicate with resident(s) due to language barrier.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in order to deliver findings for the above mentioned allegations.

Allegation 1. Resident is forced to remain in their bed while in care.
On 3/4/2022 the LPA was able to tour the facility and speak with 4 out of the 4 residents in care. LPA was also able to interview staff and the administrator regarding the allegation. All residents interviewed denied that they are forced to remain in bed. All residents stated that if they need assistance getting up, the staff is more than willing to help transfer out of bed. Resident (R1), was observed to have full bedrails at 9:15 AM, and was asked if R1 could get out of the bed. R1 stated that R1 needs help and can't move without assistance. While reviewing R1's documents, LPA observed that R1 is not currently on hospice nor did the facility have a prescription for one on file. When R1 was addmitted, R1 was on Hospice and had an order for the full bedrails, however R1 was admitted to the hospital in December of 2021 and the hospice services ended.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 31-AS-20220228145842
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HORACE ASSISTED LIVING
FACILITY NUMBER: 197609657
VISIT DATE: 04/06/2022
NARRATIVE
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On 3/4/2022, The administrator was able to reach out to R1's primary physician and a prescription for the bed rails was issued on 3/4/2022. Based on the fact that R1 is not on hospice at this time and requires assistance to get out of bed, this allegation is deemed to be substantiated.


Allegation 2. Staff unable to effectively communicate with resident(s) due to language barrier.

LPA was able to interview staff, residents, the administrator and resident representatives in order to come to a finding for this allegation. The staff member in question was interviewed at about 10:45 AM in the facility kitchen. The staff member did understand basic questions when asked in English, however the staff member was unable to answer in English. Residents interviewed did acknowledge that there is a language barrier, however they all agreed that for the most part they can get their point across. Residents did state that they have called the administrator on the phone in order to translate their needs. Family representatives stated that most communication is conducted with the administrator over the phone, but when they are at the facility alone with care staff, they are not able to communicate with the staff member effectively. The LPA was able to interview the administrator regarding this allegation and the administrator did confirm that he is aware that staff do have trouble with English. The administrator stated that he or his wife are always at the home during the day and are able to assist with communication and at night, the staff can call him to assist with any translations.
Based on interviews with residents, staff, the administrator and resident representatives this allegation is deemed to be substantiated at this time.


Exit interview conducted, deficiencies cited and report issued.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 31-AS-20220228145842
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HORACE ASSISTED LIVING
FACILITY NUMBER: 197609657
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/07/2022
Section Cited
CCR
87608(5)(b)
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Postural Supports- Bed rails that extend the entire length of the bed are prohibited except for residents on hospice and a hospice care plan that explains the reason for the full bed rail.
This requirement is not met as evidenced by:
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The facility will remove the full bed rail and put into writing their understanding of this regulation and submit it to the LPA by the POC date
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Based on observation and record review R1 has a full bed rail and a physician order but the resident was no longer on hospice and could not remove the bedrail on their own which could pose a health and safety risk to the resident in care.
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Type B
04/07/2022
Section Cited
CCR
87411(d)(3)
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Personnel Requirements:All personnel shall be given on the job training or have related experience in the job assigned to them... (3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.The requirement is not met as evidenced by: Based on observation and
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The administrator agrees to ensure that a new staffing schedule will be created to ensure that there is always one staff member who can speak English fluently. Staff schedule will be emailed to LPA as POC.
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interviews the licensee did not comply with the section above. Staff were unable to communicate effectively with residents and family due to language barrier.

This poses a potential health and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/28/2022 and conducted by Evaluator Patrick Shanahan
COMPLAINT CONTROL NUMBER: 31-AS-20220228145842

FACILITY NAME:HORACE ASSISTED LIVINGFACILITY NUMBER:
197609657
ADMINISTRATOR:TERZYAN, SEROBFACILITY TYPE:
740
ADDRESS:17355 HORACE STTELEPHONE:
(818) 439-8482
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY:6CENSUS: DATE:
04/06/2022
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Resident's toileting needs are not being met while in care.
Resident is prevented from using the toilet while in care.
Resident's Representatives requests for communication from staff are not responded to in a timely manner.
Food services are inadequate.
Resident's bed is unsanitary.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in order to deliver findings for the above mentioned allegations.

Allegation 1. Resident's toileting needs are not being met while in care.
LPA was able to interview all residents regarding this allegation. Residents interviewed confirmed that they are assisted to the restroom, whenever they request to be taken. Resident 2 (R2) and R3 do require assistance with diapers and state that the staff have never left R2 or R3 unclean. R3's power of attorney also confirmed that R3's toileting needs are being met and that this has not been a concern. LPA did not observe any strong smells of urine throughout the facility.
Based on interviews conducted and LPA observations, this allegation is deemed unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 31-AS-20220228145842
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HORACE ASSISTED LIVING
FACILITY NUMBER: 197609657
VISIT DATE: 04/06/2022
NARRATIVE
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Allegation 2. Resident is prevented from using the toilet while in care.
LPA was able to speak to all residents regarding this allegation. All residents confirmed that they are never denied using the toilet. Residents confirmed that the staff often come into their rooms and ask if they need assistance to the restroom. Residents also confirmed that if they ask staff to help them to the restroom at anytime, the staff will assist them.Based on interviews with residents, this allegation is deemed unsubstantiated.

Allegation 3. Resident's Representatives requests for communication from staff are not responded to in a timely manner.
The LPA was able to interview family representatives and the administrator regarding this allegation. The administrator stated that he knows that he is fast to reply to all family representatives. The administrator provided screen shots of text messages and emails that show that the administrator will respond within 24 hours at the latest. R2's family representative stated that communication with the administrator has never been a problem and all concerns are addressed in a timely manner.Based on interviews with the administrator, family representatives and emails and texts, this allegation is deemed unsubstantiated.

Allegation 4. Food services are inadequate.
LPA was able to tour the facilities food service area and interview residents in care. The kitchen was clean and sanitary and there was a sufficient amount of fresh foods and dry foods. All residents interviewed regarding this allegation. Residents interviewed confirmed that the food was good and that there is always enough. Residents stated that they are never denied food and that they can ask for food and will be given food when ever they want. LPA was able to observe the end of breakfast and lunch being served during the visit on 3/04/2022. Based on LPA observation and resident interviews, this allegation is deemed to be unsubstantiated.
Allegation 5. Resident's bed is unsanitary.
LPA was able to tour the facility and interview staff and residents regarding this allegation. While touring the facility, LPA observed all beds to be clean and free of any urine odors. Residents confirmed that their bedding is changed daily or every other day. Staff interviewed stated that the bedding is changed about 3 times a week or anytime there is an accident. Based on LPA observation and resident interviews, this allegation is deemed to be unsubstantiated.

Exit Interview Conducted and report issued
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Patrick ShanahanTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5